Other (Specify)

　No

　 If no, give total credit received

　STATE OF SOUTH CAROLINA EMPLOYMENT APPLICATION

　RETURN TO:

　1. APPLYING FOR:

　Job Title

　Position Number

　Location

　2. HOW DO WE CONTACT YOU?

　Social Security Number

　Your Name

　Mailing Address

　City

　County

　State

　Zip Code

　Home Phone

　( )

　 Business Phone

　( )

　 Fax Number

　( )

　 E-mail Address

　3.

　TELL US ABOUT YOUR EDUCATION:

　High School (Name)

　(Location)

　Diploma

　Highest Grade Completed

　College Graduate? Yes

　Your Name If Different While Attending School

　Give name & address of school, major course of study, and degree received.

　Undergraduate College / University

　Graduate School

　Degree

　Year Degree Obtained

　Degree

　Year Degree Obtained

　Pertinent Undergraduate Courses

　Credits

　Pertinent Graduate Courses

　Credits

　Job-Related Training and Course Work

　List any skills, licenses, and certificates which are related to the job you seek (including words per minute typing speed and computer software proficiency).

　STATE OF SOUTH

　CAROLINA - AN EQUAL OPPORTUNITY EMPLOYER

　PD- 1 DID (REVISED 6/98)

　Yes

　 No

　4. TELL US ABOUT YOUR WORK EXPERIENCE:

　Describe your work experience in detail, beginning with your current or most recent job. Include military service (indicate rank) and job related volunteer work, if applicable. Provide an explanation for any gaps in employment. All information in this section must be complete. A résumé may be attached, but not substituted for completing this section.

　1. Name of Present or Last Employer

　Address

　Phone

　( )

　 Job Title

　Number Supervised

　Supervisor"s Name

　From

　/ / To

　/ / Hours Per Week

　Salary

　May we contact this employer?

　Job Duties (give details)

　Reason for Leaving

　2. Your Next Most Recent Employer

　Address

　Phone

　( )

　 Job Title

　Number Supervised

　Supervisor"s Name

　From

　/ / To

　/ / Hours Per Week

　Salary

　Job Duties (give details)

　Reason for Leaving

　3. Your Next Most Recent Employer

　Address

　Phone

　( )

　 Job Title

　Number Supervised

　Supervisor"s Name

　From

　/ / To

　/ / Hours Per Week

　Salary

　Job Duties (give details)

　Reason for Leaving

　 4. Your Next Most Recent Employer

　Address

　Phone

　( )

　 Job Title

　Number Supervised

　Supervisor"s Name

　From

　/ / To

　/ / Hours Per Week

　Salary

　Job Duties (give details)

　Reason for Leaving

　5. Your Next Most Recent Employer

　Address

　Phone

　( )

　 Job Title

　Number Supervised

　Supervisor"s Name

　From

　/ / To

　/ / Hours Per Week

　Salary

　Job Duties (give details)

　Reason for Leaving

　6. Your Next Most Recent Employer

　Address

　Phone

　( )

　 Job Title

　Number Supervised

　Supervisor"s Name

　From

　/ / To

　/ / Hours Per Week

　Salary

　Job Duties (give details)

　Reason for Leaving

　Yes

　 No

　 A

　 B

　 C

　 D

　 E

　 F

　 M

　 G

　 Yes

　 No

　 Yes

　 No

　 Yes

　 No

　Do you possess a valid driver"s license?

　If yes, provide

　(State)

　Number

　Expiration Date

　Class: (check one)

　Do you have any relatives employed with the State of South Carolina? If yes, please provide names below:

　Name

　Relation

　Agency

　Name

　Relation

　Agency

　Have you ever been convicted of a criminal offense?

　Note: Omit minor vehicle violations and any offense committed before your 17 th

　birthday, which was finally adjudicated in juvenile court or under a youthful offender law. Conviction of a criminal offense is not a bar to employment in all cases. Each conviction is evaluated individually.

　If yes, please list charge(s)

　Where Convicted

　Date

　Disposition/Status

　Have you ever been terminated or forced to resign from any job?

　If yes, explain

　Are you legally authorized to work in the United States?

　Give the names of two people, not relatives, who are familiar with your work.

　Name

　Address

　Phone

　Name

　Address

　Phone

　PLEASE CAREFULLY READ THE FOLLOWING STATEMENTS

　Student Loan: State law (59-111-50) prohibits employment with the State to people who have defaulted on certain student loans, unless they can prove that satisfactory arrangements have been made for repayment. By my signature, I certify that I am not currently in default on a student loan.

　Signature

　Date

　Authority to Release Information: By my signature, I consent to the release of information to authorized officers, agents, and/or employees of the State of South Carolina which may include but not be limited to information concerning my past and present work; including my official personnel files; attendance records; evaluations; educational records including transcripts; military service; law enforcement records; and/or any personnel record deemed necessary. In addition, I consent to authorize appropriate officers, agents, and/or employees of the State of South Carolina to make inquiries of third parties such as credit bureaus. I further release the organization, educational entity, present and former employers, law enforcement organization, and all third parties from any and all claims of whatever nature that I may have as a result of any inquiry or response given to such inquiries made in connection with my application for employment.

　Signature

　Date

　Certification of Applicant:

　By my signature, I affirm, agree, and understand that all statements on this form are true and accurate. Any misrepresentation, falsification, or material omission of information or data on this application may result in exclusion from further consideration or, if hired, termination of employment. If I have requested herein that my present employer not be contacted, an offer of employment may be conditioned upon acceptable information and verification from such employer prior to beginning work.

　Signature

　Date

　 Male

　 Female

　American Indian / Alaskan Native

　 Asian / Pacific Islanders

　 Black / Non Hispanic

　 Hispanic

　 White / Non Hispanic

　 Yes

　 No

　 Yes

　 No

　5. EEO DATA REPORTING FORM:

　The federal government requires the following information to be collected for statistical reporting as a part of the Affirmative Action Program. Refusal to answer will not result in adverse treatment of any applicant. This information is not used in the employment process nor released in a manner which identifies the individual. This form will be removed prior to being forwarded to the hiring authority.

　Today"s Date

　/ / Social Security Number

　Last Name

　First Name

　Middle

　Position for which you are applying

　Title

　Position Number

　Sex

　(Check appropriate box)

　Date of Birth

　/ / Race (Check appropriate box)

　1.

　2.

　3.

　4.

　5.

　Will you need reasonable accommodations to participate in the selection procedures (e.g., interview, written tests, or job demonstration)?

　If yes, please notify the Personnel Office or Human Resources Office at the state agency which has the job vacancy.

　State agencies are actively supporting the Family Independence Act by hiring welfare and food stamp recipients for certain jobs. Are you currently receiving AFDC benefits or food stamps?

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